Copyright
J. A. (Joel Asaph) Allen.

Buffalo medical journal online

. (page 67 of 78)
Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 67 of 78)
Font size
QR-code for this ebook


have been placed. In some cases these quarantine establishments
or plants are maintained by the federal government, with the con-
sent of the states in which they are located, and this is especially
the case where the revenues would amount to very little. In most
instances they are maintained by the states in which the ports are
situated, and in some cases the port itself keeps up its own quar-
antine. In our larger ports the revenues derived from the dues or
tax imposed upon shipping is more than sufficient to defray all
expenses of maintenance, but in the cases of the smaller ports an
annual appropriation must be made by the state or city, and the
federal quarantines are directly provided for by Congress. The
men in control of these quarantines are federal, state or city officers,
as the case may be, all independent of each other, and working on
separate lines. Until one year ago they were absolutely free from
any supervision save by state or municipal officers, with the result
that while some were carefully and honestly administered, and
therefore trustworthy, others were quite the reverse. When the
expense of maintaining an efficient quarantine must be met by an
annual appropriation from a small and impoverished community,
there naturally exists a great temptation to curtail its efficiency,
and the country at large may be the sufferer. When the income
from fees imposed upon shipping largely exceeds the cost of main-
taining a first-class quarantine, we have a right to expect the latter,
and I am bound to say such is usually the case ; but there is a



Digitized by



Google



662 whkblbr: maritime quabantine.

strong temptation to make use of the revenues thus derived to
serve political rather than sanitary ends.

An effective quarantine plant today consists of an inspection
or boarding station, at which vessels are stopped and their people
examined, and a station of refuge, to which the sick are removed,
and all others whom it is necessary to detain, together with their
baggage. In many instances these two stations can be very well
combined. The diseases for which, by common consent, a sanitary
inspection is made, are : smallpox, typhus, cholera and yellow
fever, and provision must be made for sterilizing all personal effects,
which involves the erection of buildings and expensive apparatus.
Besides hospital buildings, houses for the detention of the well
until free from danger must be constructed, and wharves or lighters
with tugs maintained. Thus you see a very considerable expense
is needed for construction alone, to say nothing of maintenance.

Now, why should seaports, or states in which the seaports
are situated, be put to this expense when the benefit is for the
whole country at large ? And, conversely, why should the people
of the whole country be content to leave it with the sea coast
states and cities to provide such protection as they may see fit ?
Maritime quarantine deals only with foreign commerce, and the
regulation of the latter is by the constitution vested in the federal
government. The general government regulates the imposition
and collection of all duties ; it imposes a tax upon all foreign ton-
nage ; it prescribes the conditions under which, and the manner in
which, passengers may be brought to our shores; it imposes a head
tax upon foreigners for the purpose of defraying the expenses inci-
dent to carrying out its own laws ; it goes to the extent of compel-
ling foreign vessels to take on pilots when entering our ports, or,
at least, pay pilot dues. It has built a chain of custom houses
from Eastport to Brownsville on the Atlantic, and from Port
Townsend to San Diego on the Pacific, each with its detectives to
see that not a diamond or silk dress gains free admission to this
country, assisted by a navy of some twenty-five vessels, all fully
ofiicered and manned to prevent the possible smuggling of a box
of cigars or a seal skin, and yet it leaves to the State of Florida
or Georgia the task of keeping out such a frightful disease as
yellow fever, and to New York the duty of repelling cholera. The
strange spectacle is presented at our largest seaports, of United
States officers waiting for the inspection and release of all foreign
vessels by state or municipal officers, before going on board.



Digitized by



Google



WHBELEB: MABITIMB QUABANTINS. 663

I am not ignorant of the dangers which may arise from too
great centralization of power in the hands of oar National Govern-
ment, and I am a great believer in the doctrine of allowing each
stale to mind its own affairs whenever that does not interfere with
the affairs of its neighbors ; but we have here an affair which is of
vital interest to every one of the states of the Union. It is the
whole country which is building up the commerce of Boston, New
York, Philadelphia and Baltimore, and a very small percentage of
their trade is furnished by the people of their respective states.
The general government, at these and all seaports, allows of no
state interference with its custom and immigration inspection.
Why should it make an exception of the sanitary inspection ?
The whole country is aroused to the needs of our sea coast
defenses against a foreign foe, and no states are so loud in their
demands upon the general government for liberal appropriations
for this end as those states in which the defenses will be located.
No states are so persistent in their demands for an increased naval
force to protect their commerce as these same seaboard states ;
but when a revenue is to be derived, as is the case in the quaran-
tines of our larger ports, not only is the government not called
upon to provide defenses against disease, but it is requested not to
interfere in the matter as regulated by the states. One of the
functions of government is to provide protection to the governed
against a foreign foe, and we can certainly claim that two, at least,
of these contagious diseases are foreign. Cholera and yellow
fever are not native, nor have they acquired any rights by reason
of long residence.

You are aware that the New York Academy of Medicine has
prepared and had offered in Congress a bill establishing a Bureau
of Public Health in the Interior Department. This bill does not
change practically the status of the maritime quarantines, but
leaves them in the control of their respective state or municipal
officers, subject only to supervision by the General Government,
as is the case now, which supervision is now and will continue to
be more or less unsatisfactory and a constant source of irritation,
galling to the state officers, who are accountable only to their
respective states, and most disagreeable to the federal officers, to
whom is allotted the uncongenial labor of supervising the methods
and sanitary systems of quarantine officers who are not connected
with the general government. I consider the present system
weak, in that the responsibility is a divided one ; instead of being



Digitized by



Google



664 WHEELER : MARITIME QUARANTINE.

a case of two heads better than one, it is more likely to prove a
case of the proverbial broth which was spoiled by too much super-
vision. To insure a complete system of maritime quarantine,
uniform in its methods whether applied at the Atlantic or Pacific
or in the Gulf, uniform in its equipment regardless of the revenues
of any given port, affording as much protection as is possible in
any quarantine, the work must be done by the general govern-
ment. I am not opposed to the creation of a Bureau of Public
Health at the national capital, and it may very properly be
attached to the Department of the Interior, and have control in
general of all matters affecting the sanitary welfare of our people,
though I can foresee the inevitable conflict between state and
national authority, which is bound to arise if such a bureau is to
have executive powers. Whether it is best, all things considered,
for the general government to take away from the several states
the responsibility of caring for the health of their own citizens,
with all that that implies, is surely a debatable question, but that
it belongs to the government to afford us all of the protection pos-
sible against the invasion of disease from abroad seems to me to
admit of no argument. Our treasury department regulates and
controls the importation of all merchandise and peoples into these
United States, and to it should be given the absolute control of our
sea coast quarantines. If a bureau already exists in the treasury
department, familiar with this work and fully capable of conduct-
ing it, it is the part of common sense to make use of it for this
purpose. If such a bureau exists and it has not fully demonstrated
its ability to manage an efficient system of coast quarantines, then
let a new bureau be established for this special work. For a num-
ber of years the treasury department has maintained in the Gulf
of Mexico and on the South Atlantic coast refuge stations, to
which state quarantine officers in the vicinity have sent vessels
needing purification. These have been built because the Southern
States, most of them, have been too poor to provide such facilities,
and the revenue would in no way suffice for their maintenance after
being built, and the whole South is annually exposed to the intro-
duction of yellow fever from the West Indies. The general gov-
ernment, in addition to these refuge stations, has established, at
the entrance to the Delaware and Chesapeake bays, inspection
stations for the purpose of examining all vessels coming into these
waters, and it is altogether an unnecessary burden upon commerce
that the seaports in these bays should require an additional sani-



Digitized by



Google



ARTIFICIAL BB8PIBATI0N. 665

tary inspection. On the Pacific coast, the national government
has already established both inspection and refnge stations for San
Francisco, San Diego and Paget Soand. These are fully equipped
and thoroughly prepared for any possible demand that may be
made upon them.

The treasury department last year, in view of the widespread
belief that cholera would again appear in Europe, was enabled with
its own officers to establish a quarantine inspection at twelve
foreign ports, from which the disease was most likely to reach us.
What protection this afforded us I will not attempt to discuss, but
it could not have been attempted by any other than the general
government. It thus appears that there exists already the nucleus
of a federal quarantine, which could readily be developed and
extended to afford to all the people of all the states the maximum
security possible in any quarantine, with the minimum of delay
and expense to commerce under the charge of men specially trained
for the work, making of it a profession for life, independent of
state influences or party politics, working with a single purpose
and for a single object and all responsible to a common head. We
have but to look across our northern border to find the condition
such as I speak of, the Canadian government having established
most admirable quarantines at her principal ports and not leaving
to the separate provinces the task of providing defenses for the
whole Dominion.

Ellis Island, N. Y.



3ePecfionA.



ESTABLISHING A NEW METHOD OF ARTIFICIAL RES-
PIRATION IN ASPHYXIA NEONATORUM.*

Bt J. HARVIE dew, M. D., New York.

{WUh Four niuHtrationg.)

DESCRIPTION OF METHOD.

My directions for its practice are : To grasp the infant with the
left hand, allowing the neck to rest between the thumb and fore-
finger, the head falling far over backward, straightening the
month with the larynx and trachea, thereby serving to raise and
hold open the epiglottis (as demonstrated by Benjamin Howard

1. Read before the New York Academy of Medicine, February 2, 1893, and published
in the Medical Record, March 11, 18if3. Cuih kindly loaned by the Medical Record.



Digitized by



Google



666 SSLECTIONS.

in his excellent article, A New and Only Way of Raising the Epi-
glottis, British Medical Journal, November, 1888). The upper
portion of the back and scapulse resting in the palm of the hand,
the other three fingers to be inserted in the axilla of the baby's
ieft^rm, raising it upward and outward. (See Fig. 1.)

Then, with the right hand, if the baby is large and heavy, grasp
the knees in such a way as to hold them with the right knee rest-
ing between the thumb and forefinger, the left between the fore
and middle fingers. This position will allow the back of the
thighs to rest in the palm of the operator's hand. If the infant
is small and light, it will be found more convenient and easier to



Fio. 1.

hold it in the same way by the ankles instead of the knees, allow-
ing the calves instead of the thighs to rest in the palm of the
hand.

The next step is to depress the pelvis and lower extremities,
60 as to allow the abdominal organs to drag the diaphragm down-
ward, and with the left hand to gently bend the dorsal region of
the spine backward. This enlarges the thoracic cavity and pro-
duces inspiration. (See.Fig. 2.)

Then, to excite expiration, reverse the movement, bringing the
head, shoulders and chest forward, closing the ribs upon each



Digitized by



Google



▲BTIFICIAL RESPIRATION. 66*7

Other, and at the same moment bring forward the thighs, resting
them upon the abdomen. This movement arches the lambar
region backward, 'and so bends the child upon itself as to crowd
together the contents of the thoracic and abdominal cavities,
resulting in a most complete and forcible expiration. (See Fig. 3.)
While this movement is a powerful one, the operator can, by
his manipulations, accomplish it without shock and render it as
gentle as he pleases

EXPLANATION OF METHOD.

At birth an asphyxiated infant is perfectly limp and flexible.
Its muscles are like so many wet rags, and offer no resistance till
stretched out to near or about the limit of their elasticity. In



Fio. a,

the Sylvester method the ribs are not lifted till the pectoral
muscles have been put well upon the stretch, for the accomplish-
ment of which the arms must be forcibly pulled upward.

When this is done, the chest cavity is increased laterally, and
the diaphragm is flattened out, pressing the abdominal organs to
some extent downward, thus serving, in a measure, to increase the
cavity vertically. This produces the suction which every one
recognizes, and which has made this method, up to date, the most
universally known and adopted.



Digitized by



Google



668 SELECTIONS.

My method accomplishes exactly the same results in a different
way. To understand how it is done, let us consider for a moment
the anatomical structure of the chest walls. These walls are sup-
ported by, and have their fixed point in the attachment of the ribs
to the dorsal vertebrsB. They are composed mainly of the ribs^
their cartilages, the sternum and the intercostal and pectoral
muscles.

The muscles, as stated, offer no resistance and no assistance^
except for traction.

The ribs constitute not only the most prominent structure in
the formation of the chest walls, but their movements are essen-
tially important in any effort artificially or naturally to draw air



Fio. 3.

into the lungs. It is upon their peculiar arrangement, formation
and attachments that the active inspiratory movement of my
method depends.

They are twelve in number on each side, and are separated
from each other at well-defined distances. They vary in both
length and shape from the first to the twelfth. They can be made
to very closely approximate, if not to overlap each other, and are
capable of as wide a separation as the elasticity of the inter-
costal muscles will permit. They terminate at the sternum in
flexible cartilages, which vary in length and render them very
movable.



Digitized by



Google



AETIFICIAL BESPIRATION. 669

Posteriorly they have almost atixed attachment. Their heads
Are olosely l^oand by a strong ligamentous union to the bodies of
the dorsal vertebrae, while their tubercles, located nearly an inch
from their heads, are bound with equal firmness to the lateral
processes of the same vertebrae. Only a slight rotatory motion
•exists at this articulation, which, together with the peculiar shape
of the ribs and the flexibility of their anterior attachments,
•enables the normal inspiratory act to be performed, the ribs at
•each effort being drawn upward and outward.

Now comes the important fact I wish to impress. It is, that
in my method of artificial respiration, owing to the firm attach-
ment of the ribs to the bodies and processes of the vertebrae, as
«oon as the dorsal region is curved backward and the relative
position of the bodies and transverse processes is changed, the
ribs and their intercostal muscles open out like the segments of a
fan, and, at the same time, owing to their peculiar shape, all of
the bodies of the longer ribs are forced outward and the diaphragm
is flattened. Thus, both the lateral and vertical diameters of the
thoracic cavity are increased.

How much air is actually drawn in and how much reflex action
is excited by the inspiratory effort of this or any other method
in the first few movements it is difficult, from a clinical stand-
point, to determine, but after keeping up the operation for a few
moments, in any favorable case, it will be easy to recognize
unquestioned evidences of suction.

The infant whose photograph I herewith exhibit was born a
little before, and died a short while after, 7 p. m. 1 was not
present at its birth, but reached the bedside a few minutes after
•death. The photographs were taken at 11 a. m., sixteen hours
■after death. I then performed my method of artificial respiration,
and was able to force air in and out of the lungs with each move-
ment. The evidence was made positive by a very audible sound,
•excited by the escape of air at each expiratory effort.

It is very frequently, if not usually the case, when resuscitat-
ing an infant, that a decided grunt is heard with the expiratory
movement after once the introduction of air has been established.

The expiratory movement in this method is one of its most
perfect and advantageous features. Indeed, I believe that a com-
plete expiration is, for at least two reasons, of equal, if not
greater importance than that of inspiration : 1st, because if one
•cubic inch, or any given amount of air is drawn in, it is most



Digitized by



Google



670 SELECTIONS.

desirable that all of it shall* be forced oat in the movement that
follows ; 2d, becaase the expiratory effort in artifioiftl respiration
should not serve only for the expulsion of air, but should at the
same time be a means of improving and hastening the general
circulation.

If the thoracic cavity is thoroughly but gently compressed,
the heart and large blood-vessels will be unloaded in the direction
of least resistance. This, of coarse, must be forward and in the
right direction, as the cardiac aortic and pulmonary valves will
open for its forward and close upon its backward flow. The
accomplishment of this result with each expiration cannot be
otherwise than most beneficial to the sluggish circulation of an
asphyxiated infant. The Schultze method fills this requisite, as
pointed out by Dr. Lusk in his article upon this subject ; but the
action is too violent and cannot be regulated with gentleness.
The Sylvester method and its modifications, the mouth-to-month
insufflation, and inflation by catheterization, are all deficient in
this particular : they, each of them, depend for their expiratory
movement on lateral pressure over the lower ribs, upon the epi-
gastrium, or both together. This plan of expiration is objection-
able because : 1. It does not expel all of the air from the lungs,
if any has been drawn in. 2. It causes the center and posterior
portion of the flabby diaphragm to descend, thereby increasing
the vertical diameter of the chest cavity. 3. It produces but
slight, if any, pressure upon the heart and large blood-vessels
which occupy the mediastinum ; certainly not sufficient pressure
to be of any material benefit to the circulation.

In the expiratory movement of my method, when the shoulders
and chest are brought forward, and at the same moment the thighs
are made to rest upon the abdomen, including the epigastric
region, the pressure upon the contents of the thoracic cavity can
be made as forcible as the operator thinks best. The ribs are
crowded upon each other, closing up the intercostal spaces, and
the organs of the abdomen are pushed upward upon the diaphragm
so as to diminish the vertical diameter as much as it is possible to
do. By these combined forces the expulsion of air is complete,
and the desired effect upon the heart and large blood-vessels is
most favorably secured.

A METHOD MUST BE SELECTED.

Every obstetrician who finds that he has delivered an asphyxi-
ated infant proceeds at once to excite the respiratory act by reflex



Digitized by



Google



ARTIFICIAL KB8PIBATI0N. 671

stimalus. To do this be moves the infant from side to side, spanks
it, sprinkles water upon it, and possibly dips it alternately into bot
and cold water ; bat wben tbe aspbyxia is too profound to be tbii»
relieved, be is]forced to resort to some one of tbe many metbods of
artificial respiration.

Of tbe establisbed metbods Sylvester's and tbe plan of moutb-
to-moutb inflation are probably by far tbe most universally adopted,,
next tbat of Scbultze, tben catbeterization and insufflation, and
finally tbe individual plans not commonly known. One or more
of tbese metbods must be resorted to by every practitioner. Hence,
it is a matter of unquestionable importance to be able to select tbe
best among tbem, not only for individual use but for instruction
in our scbools of medicine.

As previously stated, tbe Sylvester and tbe moutb-to-moutb plan
offer good inspiratory but very imperfect expiratory movements.
Tbe Scbultze metbod, tbougb very efficient, is often inconvenient,
is too cbilling to tbe infant, and in many instances is too violent
in its movements. Catbeterization and insufflation isnot easy, and
is, as a rule, unsafe in inexperienced bands. Of tbe individual
and private metbods I bave nothing to say except of tbe one under
consideration.

In maternity hospitals where tbe obstetrician is offered every
facility, and in tbe homes of tbe wealthy where there are so many
conveniences, tbe difference between the methods of artificial res-
piration may not be a question of so much importance; but in that
very much larger class of cases occurring in the homes of tbe
middle and poorer people, where there are but few conveniences,,
he must always. endeavor to select the most ready and favorable
plan for immediate use.

In any prolonged case of aspbyxia, tbe operator will become
greatly fatigued in constantly pursuing any one of the methods
proposed, and will find great relief in practising first one plan and
tben another.

ADVANTAGES OF THIS METHOD.

I claim for my metbod the following facts and advantages :

1. That it is most efficient in all cases where artificial respira-
tion, in asphyxia neonatorum, is indicated.

2. Tbat years of experience bave served to prove to others, as
well as mvself, its unquestioned value.

3. Tnat it can be practised with ease and readiness to tbe
operator.



Digitized by



Google



672 SELECTIONS.

4. That its movements are easy and can be quickly resorted
to at any moment and anywhere.

5. That while its inspiratory movement will be found, by ex-
perience at the bedside, to be as efficient as that of other methods,
the expiratory movement is far more complete and satisfactory
than in any of them.

6. That nearly, or about all, of the air drawn in can be ex-
pelled.

7. That, owing to the force and at the same time to the abso-
lute control which the operator has over the expiratory movement,
he is able to compress the contents of the thoracic cavity to just
exactly that degree deemed by him wisest and best, thereby favor-
ing and hastening the general circulation.



Fio. 4.

8. That this method can be employed before the cord is cut,
when it seems important to save as much blood as possible to the
infant.

0. That the operator can sit or move from place to place about
the room, greatly to his relief from fatigue, still continuing the
respiratory movements.

10. That, if thought best, the movements can be kept up while
the infant is immersed up to its chin in hot water. «

11. That by elevating the buttocks and depressing the head



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 67 of 78)